Pressure ulcer-related harm: beyond root cause analysis.

The causes and contributory factors that result in pressure ulcer (PU) formation are typically identified by the use of a root cause analysis (RCA)1. RCA is founded on the high reliability theory (HRT) or the idea that health-care organisations can learn how to improve the quality and safety of care from other safety-critical industries and previous adverse events.2 HRT focuses on identifying the factors and processes that enable an organisation to consistently meet safety standards. The effectiveness of the RCA as an HRT-based quality improvement tool (QIT) for reducing PU-related harm can however be limited by the perception that it is a way of apportioning blame. Clinicians may be reluctant to disclose the root cause(s) of an adverse event because of a sense of shame; a fear of reprisals; a belief that the causes cannot be effectively addressed by their organisation;1 or concerns about the legal, financial and professional consequences of full disclosure.